Ming-Ming Tran ’15, Massachusetts General Hospital

Ming-Ming-TranDay 1: Wednesday, January 29, 2014

The first morning , I met Bobby Lucas ‘13, the research coordinator of the Orthopaedic Division at Massachusetts General. Bobby led me off to explore the various wings of the hospital, including the orthopaedic surgery wing.. On the way, we acquired a set of scrubs for me to wear in the operating room.

After returning to his office,  Bobby talked about his duties as a research coordinator. There were two types of studies: retrospective and prospective. He and his fellow research coordinator, Jordan, had to get both kinds of studies approved by the IRB (Institutional Review Board) first, which would make sure that humans were protected from physical or psychological harm. The former involved simply using data from past hospital medical records, and so required relatively little documentation, but the latter needed to collect data from current patients, and so necessitated an entire thick binder of regulatory-related documentation to follow. Bobby demonstrated the sorts of data he would collect in a retrospective study, using medical records numbers to search for medical records and then put information, such as condition x days after treatment, or whether surgery was necessary for patients with a certain injury, into an Excel file. Afterwards all the columns containing identifying information would be deleted, so it would be completely anonymous.

Then he showed me some prospectiveTran 1 studies they were working on, one of which was about the relationship between the patients’ perceived level of information about their injury on their first visit and their level of information later. These would generally be simple questionnaires that he handed to patients and asked them to fill out.  It would generally be fairly easy for him to find willing volunteers while they are sitting in the waiting room. Bobby and I talked to one such patient, and the process was simple: explain the study to the patient, hand them waiver and questionnaire, and come back for the papers five minutes later. Occasionally though, the prospective studies get more involved, like one study in which surgical patients volunteer to have chips embedded in their bones that light up brightly on X-rays, so that in later follow-up visits the doctors can take X-rays to study how the chips moved when stress was placed on the bones. This means that Bobby or Jordan would have to make sure that all the necessary equipment is in the operating room, and then be sure that the surgeons place the chips in the correct places.

After learning about these studies, we then headed to lunch in the hospital cafeteria (which had excellent soup and pizza), and then I met Yende and Peter, the other two Princeterns. Bobby took me and Peter to watch some surgeries in the orthopaedic wing. We first checked a TV near the reception desk to see what surgeries were scheduled for that afternoon and where. Having acquired a target, we put on more sterility gear in addition to our scrubs, namely, hair nets, face masks, and interestingly, shoe covers. It felt bizarre, because in research labs so often the most critical piece of protective equipment are the goggles, yet here the only thing left uncovered were the eyes. It struck me that perhaps it was because in research, we try to protect ourselves from the experiment, while in medicine, we protect the patient from us.

Our first surgery was the setting of a right ankle fracture, of a pedestrian hit by a vehicle. Before the surgery there is an official “pre-surgical huddle” in which the doctors and nurses confer to be sure everyone is up-to-date, on things as simple as which ankle is the one being operated upon, to things such as which sort of operating table should be used. We watched, fascinated (and trying to keep out of the way), as two surgeons literally took a drill to a man’s bone in order to insert a plate and screws. Despite the businesslike atmosphere of the operating room, everyone was not completely formal—there were still lighthearted discussions of who had eaten at which restaurant the night before, and the nurses were kind enough to turn on cameras that were placed directly on the lamps so that we could have a better view of the surgery. This did not mean, however, that the surgery was not skillfully done. Great precautions were taken to keep the surgical area sterile, with blue sheets covering most of the patient’s body to prevent contamination. I was surprised by how little blood there was—use of a tourniquet beforehand meant that when the patient’s leg was cut open, there was almost no bleeding at all and his muscles were pale in color. More shocking, however, was when the surgeons pulled out a drill and simply began drilling screws into the patient’s bone. I kept wincing and expecting something to splinter, but everything went as planned. Afterwards I was amazed at how well the surgeons had aimed the screws in order to realign the bone, despite only having glances at X-rays to compare. To confirm that the job was properly done, a large X-ray machine (wrapped somewhat comically entirely in plastic to prevent contamination) was brought in that could examine the patient directly on the operating table before he was finally stitched up.

The second surgery we watched was a much shorter and less involved procedure. A patient got an external fixator removed—a metal contraption that stabilizes bones,  but has to remain outside the body yet screwed to the bone. The original installation was done overseas, and the surgeons noted how loose the screws have gotten, but despite this,  the patient’s pelvic bone fracture had healed and the surgeon simply removed several screws and twisted the metal rods out of the patient’s abdomen. I watched with some confusion and incredulity that doctors could actually drill metal rods and plates and screws into people’s bones and instead of harming the bone, it would help it to heal.

Tran 2Day 2: Thursday, January 30, 2014

The second morning was an early one—6:20 am meet up with Bobby in order to go to x-ray and card rounds. We listened to the attendings discuss the patients who had come in the night before, looking at their X-rays and debating appropriate treatments and approaches to take. It was quite an intimidating gathering of minds! Afterwards, I met Kathy Burns, the nurse practitioner, who had been in rounds, and she and another doctor, Dr. Smith, embarked on their whirlwind schedule of patients to check up on. There were a huge variety of patients, seemingly all in different floors of different buildings, and I marveled at their ability to remember which patient had what condition. Incidentally, both of the patients whose operations I saw yesterday were on her list, and they were doing just fine. In addition, we met a skier in an accident who was close to my age, an elderly 80-year-old man who thought he was still in his house, a surprisingly sprightly 94-year-old woman, and a woman who had a bone infection and possibly needed amputation. In addition, Kathy also had to conduct more miniature rounds throughout the day for different wings of the hospital, keeping the various departments informed about the discussions during rounds, including physical therapists and nurses.

Kathy led me to meet Suzanne Morrison ’89, the program director who has been our main contact for this Princeternship.  After lunch, Suzanne took me to the Ether Dome, a historical landmark of Boston, which contains pictures and displays related to the history of anesthesia. I laughed upon seeing that seven years after a famous scientist had said that surgery without pain was unattainable, anesthesia was first used in a surgery—and it was successful. Next, she took me to meet briefly with Dr. Torri, the anesthesiologist whom I would shadow the following day. We agreed on a meeting time and place, and then Dr. Torri had to go attend to surgeries while Suzanne finally took me to the Paul S. Russell, MD Museum of Medical History and Innovation, affiliated with Massachusetts General, which contained all sorts of cool exhibits about the first microscope and how social movements affected the hospital.

Day 3: Friday, January 31, 2014

On my last day I met Dr. Torri at 6:45 am in my scrubs. As we headed to the operating room, he explained to me that he was only scheduled for one surgery that day, but it was a fairly major one. The patient was one of those strange luck stories that you read about in Reader’s Digest—he had been a pedestrian in a car accident, and while X-rays of his chest were being taken, the doctors noticed something in his spine. It turned out to be a cancer in one of his vertebrae, and required two major spinal surgeries. If it had not been for the accident, the cancer might have been asymptomatic for several more months! The first surgery had already been performed ten days prior, which removed the spinous processes of the affected vertebra and fused together the other vertebrae around it, and today’s surgery was to remove the entire vertebral body and replace it with a metal support.

First we went to visit the patient in the pre-operating room. Dr. Torri made sure that the patient was comfortable, had enough pain medication, was fully informed about his surgery, had up-to-date allergy information, and the like. I had never really thought about how personable a doctor has to be, even if most of the time his patients are asleep! Dr. Torri also allowed me to listen to his heartbeat with a stethoscope, which was much more exciting than I expected—it boggled the mind that I was literally listening to the sound of his heart valves!

Before the operation could begin, the staff needed to prep the operating room. There were discussions about the type of bed desired—one that could hold the patient laterally, but was also X-ray transparent—and Dr. Torri needed to collect together all the types of chemicals he needed,  which included anesthetics, muscle paralyzers and medications that could regulate blood pressure. There were at times ten people in the room at once, which required an incredible amount of communication, as they worked together to go through the necessary safety procedures, determining the ideal set up of the bed and anesthesia machines and equipment, etc. I met Shauna Williams, the other half of Dr. Torri’s anesthesiological team for this surgery, and she too answered all of the questions I had about their procedures.

Dr. Torri put the patient to sleep and the nurses and orderlies had to roll the patient gently onto the operating table, then attach several more lines to him. Dr. Torri explained that this was so that if the began losing a lot of blood, they would be able to intravenously give him more blood quickly. The total came to five IV lines attached and resulted in a maximum flow rate of 450 mL/min—almost half a liter per minute! Dr. Torri then explained basics such as needle size (larger number means a narrower needle), how to determine a good vein for an IV,  how to insert the needle, and how to set up an IV bag of saline solution. I stood back and simply marveled at how many people were necessary to help one man, with nurses and Dr. Torri integrating the intubation already attached to his hospital bed into the equipment of the OR, taping the patient’s arms down with foam, and checking to see that all the lines were not crushed by the patient’s own weight. Things I had never thought of—like taping the eyes closed to protect the cornea—were all taken care of systematically. Like the surgery I had watched the first day, the patient was once again entirely covered in blue sheets, until the small section of his body to be cut up seemed unconnected to the man I had talked to a few hours before.

Eventually the surgery itself began and I was able to watch the electric knife sweep through the skin and simultaneously cauterize as it cut, so it bled very little.  I saw just how strong bone could be when the surgeon began taking a saw to it in order to remove the cancerous vertebra, and just how dangerous cancer was when said vertebra was removed but the surgeons told the nurses not to touch it even with gloves on, and had it wrapped in a towel then put in a separate container. At this point, the portable X-ray machine is brought in again as a checkpoint for the surgeons, and then replacement of the vertebra with a metal bit begins. This however requires a bone graft in order to help the bone to grow around the implant, and for that the surgeons turn to the iliac crest—the part of your pelvic bone that sticks out on the hip. They removed bone by scraping tiny scoops of bone off the iliac crest and putting it into a container. After enough was collected, it was put onto the implant. Final X-rays were taken, and a doctor stitched up each layer meticulously. Dr. Torri woke the patient up and told him that the surgery has gone perfectly.

Dr. Torri was soon paged for another surgery. An older woman with severe back pain was to have some of her vertebrae fused. As a former pediatrician, this patient was much more informed  and quickly told Dr. Torri what he needed to know. She also warned him repeatedly that she might lose blood pressure very quickly, and Dr. Torri promised to watch out. Dr. Torri warned me that this surgery was likely to go late, perhaps until 6 pm, and so I told him I needed
to leave earlier than that to catch a train After the patient was fully under and the surgery was about to begin, I took my leave of Mass General sadly.

I would highly recommend this Princeternship, because of the abundance of helpful staff around who are willing to explain everything and the wide variety of patients to encounter. I am definitely much more informed about what a hospital environment is like and what being a doctor actually entails, and I have gained a lot of confidence in my decision to be premed. Thank you in particular to Bobby, Ms. Burns, Ms. Morrison, Ms. Williams, and Dr. Torri for your patience and help, and I really hope I can return one day, either just to shadow or perhaps even as a real medical student!